laparoscopic-assisted resection of meckel¢â‚¬â„¢s diverticulum...
Post on 16-Oct-2020
Embed Size (px)
Laparoscopic-Assisted Resection of Meckel’s Diverticulum in Children
Sai Prasad TR, MRCS, MCh, Chan Hon Chui, FRCS, FAMS, Anette Sundfor Jacobsen, FRCS, FAMS
Background and Objectives: Meckel’s diverticulum (MD) presents unique challenges for a pediatric surgeon, as it is prone to varied complications. This case series highlights the diverse presentations and laparoscopic management of MD in children.
Methods: We performed a retrospective analysis of con- secutive cases of laparoscopic-assisted transumbilical Meckel’s diverticulectomy (LATUM) performed by the same surgeon for incidental as well as diverse Meckel’s diverticular complications over 20 months.
Results: Eight patients (5 males and 3 females) aged 3 years to 13 years (median, 12) underwent LATUM. Three patients had painless per-rectal bleeding and 1 presented with intestinal obstruction due to a mesodiverticular band and intestinal ischemia. Two patients had features mas- querading as appendicitis; one had perforated MD with secondary inflammation of the appendix, and the other had a torsed, gangrenous MD. In 2 patients, incidental MD with a narrow base was noted at appendicectomy for appendicitis. All patients underwent successful LATUM along with appendicectomy in 4 patients. The operative duration was 72 minutes to 165 minutes (mean, 112.1�30.6). There were no operative complications, and no conversion to open surgery was required. The hospital stay was 4 days to 7 days (mean, 4.7�1.2). The patient with mesodiverticular band intestinal obstruction pre- sented with adhesive intestinal obstruction 2 weeks after the surgery. Laparoscopic-assisted minilaparotomy was done to release the pelvic adhesions. There were no other complications during the follow-up (median, 11 months).
Conclusions: LATUM is a simple, safe, and effective
procedure with a better cosmetic outcome that can be performed for diverse manifestations of MD. The tech- nique also allows palpation of the MD and avoids use of expensive staplers.
Key Words: Meckel’s diverticulum, Complications, Chil- dren, Laparoscopy.
Laparoscopy has opened new avenues in the manage- ment of Meckel’s diverticulum (MD), which poses differ- ent challenges to a clinician. Traditional investigative modalities like 99mTechnetium (99mTc) scintigraphy, radiographic contrast studies, ultrasonography, and com- puted tomography scan have many limitations in the ac- curate assessment of MD and its complications. Laparos- copy aids in the diagnosis and treatment of diverse complications associated with MD. Laparoscopic-assisted transumbilical Meckel’s diverticulectomy (LATUM) is a simple, safe technique for the precise assessment of the complications of MD and performing the resection.1–4
Although laparoscopic intracorporeal Meckel’s diverticu- lectomy can be accomplished with staplers5 or a pretied Endoloop,6 extracorporeal resection has the advantages of a simplified technique with a minimal number of ports and avoids the expensive staplers. This case series is unique as it is only the second series reported in the English language literature to depict the diverse forms of Meckel’s diverticular complications successfully treated by LATUM.7
A retrospective analysis of consecutive cases of LATUM performed by the same surgeon for incidental as well as diverse complications of MD during the study period from January 2004 and August 2005 was done. The presenting features, clinical signs, investigations, operative proce- dure, follow-up, and complications were noted and the safety and efficacy were analyzed.
Department of Paediatric Surgery, KK Women’s and Children’s Hospital, l00, Bukit Timah Road, Singapore 229899 (all authors).
Presented at the 14th International Congress and Endo Expo 2005, SLS Annual Meeting, San Diego, California, USA September 14–17, 2005 and at IPEG’s 14th Annual Congress for Endosurgery in Children, Venice Lido, Italy, June 1–4, 2005
Address reprint requests to: Sai Prasad TR, Department of Paediatric Surgery, KK Women’s and Children’s Hospital, 100, Bukit Timah Road, Singapore 229899. Telephone: 65–63941113, Fax: 65–62910161, E-mail: firstname.lastname@example.org
© 2006 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by the Society of Laparoendoscopic Surgeons, Inc.
LATUM was performed through 3- or 2-port laparoscopy. A 10-mm port for the telescope was inserted through the umbilicus by an open Hasson’s technique. Two 5-mm working ports were inserted in the suprapubic region and the left iliac fossa under vision after pneumoperitoneum was established. The second working port was omitted in cases of bleeding MD. Systematic exploration of the small intestine was performed in a retrograde fashion from the caecum. The intestinal loops were walked through eval- uating the intestine on either side of the mesentery as cursory examination might overlook a small MD adherent to the mesentery. In the case of mesodiverticular band intestinal obstruction, the collapsed loops were walked towards the site of the obstruction with minimal handling of the proximal dilated intestinal loops. The MD was released from the mesentery after coagulating and divid- ing the feeding vessel. The MD was grasped with a Bab- cock forceps passed via the umbilical port through a reducer, visualizing with a 5-mm telescope through the working port. The umbilical incision was extended with a generous incision of the linea alba, but the skin incision remained within the umbilical cicatrix. The MD was brought out of the umbilical incision. Resection of the MD with a sleeve of ileum and hand-sewn single-layered end-
to-end anastomosis with interrupted 4–0 polyglactin sutures was performed extracorporeally. The anastomosed intestine was replaced back into the peritoneal cavity, and the umbil- ical incision was closed with few interrupted sutures of 2–0 polyglactin to approximate the linea alba (Figure 1).
One case of torsed MD was handled with a modification of the technique. The narrow base of the torsed MD was ligated with a pretied loop suture (Vicryl Endoloop, Ethi- con) and divided between the ligatures. The unruptured MD was retrieved through the umbilical incision avoiding spillage into the peritoneal cavity. Appendicectomy was accomplished simultaneously in 4 patients. The appendix was delineated and the mesentery was fulgurated with bipolar or monopolar hook diathermy and divided with scissors. The appendicular base was ligated with a single pretied Vicryl Endoloop suture. The appendix was di- vided between ligatures, the distal appendicular side of the ligature being tied using the same Endoloop suture with a slipknot tied manually. The appendix was retrieved through the umbilical port or the umbilical incision.
Eight patients (5 males and 3 females) age 3 years to 13 years (median, 12) underwent LATUM (Table 1). Three
Figure 1. Stepwise depiction of laparoscopic-assisted transumbilical Meckel’s diverticulectomy; A: laparoscopic view of incidental Meckel’s diverticulum with acute appendicitis, B: Meckel’s diverticulum brought out of umbilical incision, C: completed end-to-end anastomosis after resection of Meckel’s diverticulum, D: Appearance of umbilical incision after laparoscopic-assisted transumbilical Meckel’s diverticulectomy.
JSLS (2006)10:310–316 311
Table 1. Clinical Description of the LATUM Cases
Case* Age/Sex* Symptoms* Signs* Investigations* Surgery Findings* Surgery* Complications*
1 5y6m/M Abd pain, vomiting
& fever for 3 days
Tender and guarded
Hb: 12.9 g/dL; TLC:
USG & CT scan abd:
Inflammatory mass in the
lower abdomen with
Histo: Meckel’s diverticulitis
Meckel’s diverticulitis with
perforation and forming a
mass with adjacent loops
2 12y2m/F Abd pain, vomiting
and fever for 1 day
Tender RIF Hb: 15.4 g/dL; TLC:
Histo: Acute appendicitis
and MD (No heterotopia)
Appendicitis and incidental
3 5y2m/F PR bleeding and
pallor for 1 day
Fresh PR bleeding,
Hb: 9.6 g/dL; TLC: 12�109/L
Histo: MD with hemorrhagic
peptic ulcer at base and
MD and blood filled distal
4 2y9m/M PR bleeding, cold
hands & feet and
pallor for 1 day
stools on PR
Hb: 6.6 g/dL; TLC:
14.7�109/L 99mTc scan: Consistent with
Histo: MD with gastric &
MD and blood filled distal
5 12y2m/F Abd pain, vomiting
and abd distension
for 4 days
Distended abd with
Hb: 14 g/dL; TLC:
AXR: Distended small bowel
& air fluid levels
Histo: MD with congestion
and ischemic changes. No
intestinal obstruction with
congestion of dilated
LATUM Adhesive IO
2 weeks later
6 13y5m/M Abd pain, fever and